Low carb for doctors: diabetes medications

Let’s think for a bit about the patients who are already on drugs
for the type 2 diabetes. This is something I’ve worried
about quite a lot over the years. And particularly at the beginning
I was very concerned. So that actually it might for many of you
be quite a good thing to start with some of the easier cases and then like me you will gain
confidence as the years go by and learn what for you feels comfortable. So for me I actually was very cautious and years ago I started
just with the pre-diabetics. And then I moved on
to pick with type 2 diabetes and then my next phase
was people on metformin. And I discovered actually that
it works reasonably well as the weight comes down and the hemoglobin A1c’s improve once you’re getting somewhere around
maybe 47 to 50 mM/mole of hemoglobin A1c you can start cutting the metformin. Now this has to be seen against
the patient’s views as in all of these things. You work in collaboration
with the patient, so you’ve got your own goals but don’t forget the patient’s goals
or anxieties. So that again going back
to that metformin some patients already have
side effects with metformin, particularly loose motions
that’s very common, so those patients are keen to give it up
and I factor that in. But usually I’m cutting it down
by about half perhaps just leaving them
with their morning dose of metformin and then let’s do another hemoglobin A1c
two months later. But it does depend
on how much weight they’re losing. If they’re doing really well
you might consider stopping it altogether. And all advice against what you’re doing
with drugs for diabetes would depend upon extra factors
like, “Have they got a blood sugar meter?” Because patients with blood sugar meter, you can act faster
because you’re getting feedback and you know how they are doing. So I think after that my next group
were those on Gliclazide. Now Gliclazide,
one of its side effects is weight gain. So for many patients,
they are interested in giving up Gliclazide because of the advantages of that. So far in my own experience
for somebody losing weight, I’ve given up the Gliclazide
totally early on and I’ve so far not regretted that. So that if somebody is really taking up
the low-carb thing and understands, I might stop the Gliclazide altogether in a more dramatic sense
than I do the metformin. Of course after that there are
whole other levels of extra drugs perhaps culminating in insulin. Now I didn’t do anything with people
on insulin with type 2 diabetes for the first couple of years, because I was so anxious about that. But then again looking at the effects
of insulin in type 2 diabetes it’s perhaps unfortunate
that it causes weight gain and the studies show that insulin is not
always the best idea in type 2 diabetes and brings with it real risks of its own. So again in partnership
with the patients, reducing insulin can be exactly
what they would like to do. How you do this depends on factors
like, “How reliable is this patient?”, if they’re on insulin
they should be measuring blood sugars, “are they doing it?”, when are they measuring
those blood sugars… One of my partners pointed out that he found his patients were measuring
blood sugars first thing in the morning, not after they had food, so the results they were bringing in
were causing errors. So are you patients…
when are they measuring their blood sugars and how interested are they in reducing
the insulin in a step or alike manner while watching the blood sugars. And also I suppose you would have
to share with the patients you’re more concerned about
a low blood sugar, them going hypo, than you are about it going a bit high. So one or two slight worries
I’ve had with patients is where they’ve been too keen,
the blood sugars dropped low, and these are people
driving cars or whatever, so I’ve now tend to… slightly on the idea that is a low blood sugar would worry me
more than it going high. And it is difficult
to be more specific than that, because each case depends
upon all those various factors. I’ll probably finish off by saying those
people who were on insulin for type 2 diabetes are the group who are most proud
of their achievements and are amazed
when they can actually stop injecting. So it is work that is worth doing,
although it does take more appointments, because you’re watching them
more closely. But it can be very rewarding to try as long as it’s what you patient
is really interested in.

Reader Comments

My doctors wanted me to stay on metformin after I lost weight. Actually had to be insistent about stopping it. Why would they recommend metformin as a heart protection medication? My A1C was normal. No issues with my heart. Weight loss was about 50 lbs. Doctors also pushed insulin on my Dad as a type 2 diabetic.